University of Nevada, Reno. Functional Analysis of Motor and Vocal Stereotypy: It s Not Always Automatic

Transcription

1 University of Nevada, Reno Functional Analysis of Motor and Vocal Stereotypy: It s Not Always Automatic A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Psychology by Maria T. Stevenson Dr. Patrick M. Ghezzi/Dissertation Advisor December 2015

2 UNIVERSITY OF NEVADA RENO THE GRADUATE SCHOOL We recommend that the dissertation prepared under our supervision by MARIA THU TRANG STEVENSON entitled Functional Analysis of Motor and Vocal Stereotypy: It s Not Always Automatic be accepted in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Patrick M. Ghezzi, Ph.D., Advisor Linda J. Hayes, Ph.D., Committee Member W. Lawrence Williams, Ph.D., Committee Member Stephen L. Rock, Ph.D., Committee Member Maryann Demchak, Ph.D., Graduate School Representative David W. Zeh, Ph.D., Dean, Graduate School December, 2015

3 i Abstract This study systematically evaluated social variables to determine their influence on automatically reinforced, stereotypical behaviors. Three experiments were designed to determine the effect of diverse demands, tangibles, and forms of attention on motor and/or vocal stereotypy for seven children diagnosed with autism. Results suggested that specific demands, tangibles, and types of attention can contribute to the maintenance of stereotypy; even after an initial functional analysis indicate that the behaviors are automatically reinforced.

4 ii This Dissertation is dedicated to my supportive, patient, and loving family: Michael Gadberry, Maddalyn Gadberry, Thu Stevenson, David Stevenson

5 iii Table of Contents Abstract... i Dedication... ii Table of Contents... iii List of Tables... vi List of Figures... vii Appendix... xiii Introduction... 1 The Form, Function, and Treatment of Stereotypy... 2 Identifying the Function of Motor and Vocal Stereotypy... 5 Indirect Assessments... 5 Descriptive Assessments... 5 Functional Analysis... 6 Specific Assessments and Analyses for Motor and Vocal Stereotypy... 7 Conditional Analyses for Non-Stereotypical Behaviors... 9 Negative Reinforcement Analyses... 9 Positive Reinforcement Analyses: Tangibles Positive Reinforcement Analyses: Attention Reinforcement Analyses for Motor and Vocal Stereotypy Methodology Participants and Settings Behavior Definitions... 15

6 iv Data Collection & Response Measurement Interobserver Agreement Procedural Integrity Functional Behavior Assessment Functional Analysis Ignore Condition Attention Condition Tangible Condition Demand Condition Play Condition Experimental Design & Interpreting Functional Analytic Data Experiment I: Demand Analysis Treatment Protocol: Participant Experiment II: Tangible Analysis Treatment Protocol: Participant 6a Experiment III: Attention Analysis Treatment Protocol: Participant 6b Results Functional Behavior Assessment Functional Analysis Experiment I: Demand Analysis Treatment: Participant Experiment II: Tangible Analysis... 31

7 v Treatment: Participant 6a Experiment III: Attention Analysis Treatment: Participant 6b Discussion References... 42

8 vi List of Tables Table 1. Demographic characteristics for all participants and definitions of stereotypical behaviors Table 2. Functional behavior assessment results for all participants Table 3. Summary of items utilized in functional analytic conditions for all participants Table 4. Demands utilized during Demand Analysis conditions for Participant Table 5. Demands utilized during Demand Analysis conditions for Participant Table 6. Demands utilized during Demand Analysis conditions for Participant Table 7. Demands utilized during Demand Analysis conditions for Participant Table 8. Demands utilized during Demand Analysis conditions for Participant Table 9. Demands utilized during Demand Analysis conditions for Participant 6a Table 10. Demands utilized during Demand Analysis conditions for Participant 6b Table 11. Demands utilized during Demand Analysis conditions for Participant 7a Table 12. Demands utilized during Demand Analysis conditions for Participant 7b Table 13. Leisure items utilized in the Tangible Analyses for all participants... 62

9 vii List of Figures Figure 1. Results of the Functional Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 2. Results of the Functional Analysis for Participant 2. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 3. Results of the Functional Analysis for Participant 3. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 4. Results of the Functional Analysis for Participant 4. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 5. Results of the Functional Analysis for Participant 5. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Figure 6. Results of the Functional Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Figure 7. Results of the Functional Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 8. Results of the Functional Analysis for Participant 7a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions... 70

10 viii Figure 9. Results of the Functional Analysis for Participant 7b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 10. Results of the Demand Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 11. Results of the Demand Analysis for Participant 2. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 12. Results of the Demand Analysis for Participant 3. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 13. Results of the Demand Analysis for Participant 4. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 14. Results of the Demand Analysis for Participant 5. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Figure 15. Results of the Demand Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Figure 16. Results of the Demand Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 17. Results of the Demand Analysis for Participant 7a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions... 79

11 ix Figure 18. Results of the Demand Analysis for Participant 7b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 19. Results of the Demand Analysis treatment for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred throughout demand fading Figure 20. Results of the mid-treatment Demand Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 21. Results of the post-treatment Demand Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 22. Results of the preference assessment for Participant 1. Data reflect the percentage of times each item was selected Figure 23. Results of the preference assessment for Participant 2. Data reflect the percentage of times each item was selected Figure 24. Results of the preference assessment for Participant 3. Data reflect the percentage of times each item was selected Figure 25. Results of the preference assessment for Participant 4. Data reflect the percentage of times each item was selected Figure 26. Results of the preference assessment for Participant 5. Data reflect the percentage of times each item was selected Figure 27. Results of the preference assessment for Participant 6a. Data reflect the percentage of times each item was selected

12 x Figure 28. Results of the preference assessment for Participant 6b. Data reflect the percentage of times each item was selected Figure 29. Results of the preference assessment for Participant 7a. Data reflect the percentage of times each item was selected Figure 30. Results of the preference assessment for Participant 7b. Data reflect the percentage of times each item was selected Figure 31. Results of the Tangible Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 32. Results of the Tangible Analysis for Participant 2. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 33. Results of the Tangible Analysis for Participant 3. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 34. Results of the Tangible Analysis for Participant 4. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 35. Results of the Tangible Analysis for Participant 5. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Figure 36. Results of the Tangible Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Figure 37. Results of the Tangible Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions

13 xi Figure 38. Results of the Tangible Analysis for Participant 7a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions. 100 Figure 39. Results of the Tangible Analysis for Participant 7b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 40. Results of the Tangible Analysis treatment for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred throughout phases Figure 41. Results of the post-treatment Tangible Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Figure 42. Results of the Attention Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 43. Results of the Attention Analysis for Participant 2. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 44. Results of the Attention Analysis for Participant 3. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Figure 45. Results of the Attention Analysis for Participant 4. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 46. Results of the Attention Analysis for Participant 5. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions. 108

14 xii Figure 47.Results of the Attention Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions. 109 Figure 48. Results of the Attention Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 49. Results of the Attention Analysis for Participant 7a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions. 111 Figure 50. Results of the Attention Analysis for Participant 7b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Figure 51. Results of the Attention Analysis treatment for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred during phases Figure 52. Results of the post-treatment Attention Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions

15 xiii Appendix Appendix A. Example of Functional Analysis Screening Tool - Revised Appendix B. Example of Demand Assessment data sheet

16 1 Functional Analysis of Motor and Vocal Stereotypy: It s Not Always Automatic Introduction Motor and vocal stereotypy can take many forms, from rocking and tapping a finger to blurting out nonsensical, words and phrases repeatedly. These types of behaviors are common in individuals with autism and developmental delays (DiGennaro- Reed, Hirst & Hyman, 2012). While they may not be damaging their bodies, people who engage in motor and/or vocal stereotypy almost always experience a decrease in quality time spent with family members. As well, these behaviors often interfere with learning opportunities in academic and vocational settings and their occurrence tends to inhibit learning appropriate social behavior. When isolating the reinforcement function for stereotypical behaviors, the conclusion is typically automatic, as in automatic reinforcement (DiGennaro-Reed, Hirst & Hyman, 2012; Hanley, Iwata & McCord, 2003; Rapp & Vollmer, 2005). The interpretation is the consequences for these behaviors arise from the stimulation generated by making the response itself (DiGennaro-Reed, Hirst & Hyman, 2012; Hanley, Iwata & McCord, 2003; Rapp & Vollmer, 2005). The assumption that motor and vocal stereotypy is automatically reinforced is not always accurate, however. Wilke, Tarbox, Dixon, Kenzer, Bishop, & Kalavand (2012), for example, conducted an indirect functional assessment of stereotypy with 53 children with autism. The Questions about Behavioral Function questionnaire was administered to parents and caregivers, and the results indicated that for 35 out of 53 participants (66%), motor and/or vocal stereotypy was automatically reinforced. For the remaining 18 participants, stereotypy was socially reinforced.

17 2 Like Wilke et al. (2012), a growing number of studies indicate that sometimes these behaviors are socially reinforced, for instance, by avoiding or escaping from demands and instructions issued by a parent or teacher (Cunningham & Schriebman, 2008; Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994; Kennedy, Meyer, Knowles, & Shukla, 2000). Despite periodic calls to take greater care in identifying an automatic function for stereotypy, there is still no formal or systematic method for confirming, whether or not social reinforcers are involved (Rapp & Vollmer, 2005). The implications of this omission are discussed in detail below. This dissertation is focused on an experimental analysis of motor and/or vocal stereotypy with young children with autism. The research necessarily includes a functional behavior assessment (FBA) and an initial functional analysis (FA) indicating that the stereotypical behavior is automatically reinforced. With this information in hand, an analysis was made first, of the FBA procedure for identifying an automatic function, and second, how treatment for several children was affected by the FBA analysis. We begin with a review of current methods used to assess the various functions of behavior. The Form, Function, and Treatment of Stereotypy Motor and vocal stereotypical behaviors comprise a wide range of forms including hand flapping, twirling hair, squinting, staring at lights, humming, rocking, echolia, and repeating random sounds. Typical definitions for these behaviors refer to them as repetitive, proprioceptive, unrelated to the situation, non-functional, invariant, rhythmic, lacking social value, or producing visual, vestibular, tactile, or auditory stimulation (Berkson, 1967; Cunningham & Schreibman, 2008; Lovaas, Koegel,

18 3 Simmons & Long, 1973; Lovaas, Newsom, & Hickman, 1987; Rapp & Vollmer, 2005; Repp & Horner, 1999; Rincover, 1978). The behavior is assumed to be reinforced automatically, and for this reason, it is further assumed that the variables controlling the behavior are difficult if not impossible to manipulate (Cunningham & Schreibman, 2008). Skinner (1953) first utilized the term automatic reinforcement to conceptualize, for instance, how scratching an itch or twirling a piece of hair can produce its own reinforcement. The term has been utilized since to distinguish between behaviors that are maintained by nonsocial and social contingencies of reinforcement (Repp & Horner, 1999; Vaughan & Michael, 1982). The difference is between behaviors that require the participation of another person, on the one hand, and those that do not, on the other hand. According to Vaughan & Michael (1982), Skinner focused on automatic reinforcement to emphasize how easy it is to overlook the wealth of behaviors under the control of this particular source of stimulation. The term, in Vaughan & Michael s view, was used to counteract any tendency to restrict the concept of reinforcement to those occasions upon which it has been deliberately arranged by another person or group (P. 218). Automatic reinforcement is regarded as a natural result of behavior and may be conditioned or unconditioned, positive or negative, or verbal or nonverbal. When assessing stereotypical behaviors, an automatic function is usually identified and a treatment based on this function is developed. Treatment options for automatic functions include reinforcer substitution (Piazza, Adelinis, Hanley, Goh & Delia, 2000; Rapp, 2006), manipulating motivational operations (Lang, O Reilly, Sigafoos, Lancioni, Machalicek, Rispoli & White, 2009; Roantree & Kennedy, 2006),

19 4 differential reinforcement (Kennedy, Meyer, Knowles & Shukla, 2000; Repp, Dietz & Dietz, 1976), punishment (Ahrens, Lerman, Kodak, Worsdell & Keegan, 2011; Anderson, Doughty, Doughty, Williams, Saunders, 2010), and sensory extinction (Kennedy & Souza, 1995; Rincover, 1981). These treatments, alone or in combination, are usually effective in reducing the frequency and duration of automatically reinforced stereotypy. The question as to whether or not the stereotypical behavior is actually automatically reinforced is seldom raised, however. Could the reinforcement for the behaviors spring from a social source? A handful of researchers have explored this question and have discovered that for some individuals, stereotypy is a socially reinforced behavior. When this is the case, treatment based on a social function, as opposed to a non-social, automatic function is clearly the proper way to proceed. Research on stereotypical behaviors reinforced by social consequences has yielded several effective treatments, all of which are based on positive reinforcement (Kennedy, Meyer, Knowles & Shukla, 2000; Lancaster, LeBlanc, Carr, Brenske, Peet & Culver, 2004; Mace & Lalli, 1991) and negative reinforcement (Durand & Carr, 1987; Kennedy, Meyer, Knowles & Shukla, 2000; Mace & Belfiore, 1990). Our point in drawing attention to social and non-social sources of reinforcement and the treatments that follow from these sources for stereotypy is this: When stereotypy is automatic, treatments based on this non-social function are likely to be effective. When stereotypy is instead socially reinforced, treatments based on that function are likely to be effective. The converse is also true: When stereotypy is socially reinforced, treatments

20 5 based on an automatic function are unlikely to be effective, and when stereotypy is automatic, treatments based on a social function likewise are unlikely to be effective. We turn next to the methods utilized in identifying the function of motor and vocal stereotypy. Identifying the Function of Motor and Vocal Stereotypy One of three types of FBAs can be utilized to determine what reinforces motor and vocal stereotypy: indirect assessments, descriptive assessments, and functional analysis. Indirect Assessments. Indirect assessments involve conducting interviews or completing checklists or rating scales with parents, caregivers, or teachers. Commonly asked questions refer to when stereotypy occurs (e.g., does the behavior occur when no one is around, when leisure items are present, or is it cyclical in nature), what happens when it occurs (e.g., redirection, ignore), and how the behavior appears (e.g., does the behavior appear to be self-stimulatory?) (Durand & Crimmins, 1987; Wsiseler, Hanson, Chamberlain & Thompson, 1985; Zarcone, Rodgers, Iwata, Rourke, & Dorsey, 1991). Data gathered during these interviews are based on verbal report, which may or may not be accurate. Descriptive Assessments. Direct observations of behavior that occur in naturalistic settings are identified as descriptive assessments. Data may be collected throughout the school day, for example, or at home during different parts of the day. Bijou, Peterson & Ault (1968) (see also Touchette, MacDonald, & Langer, 1985) illustrate the approach, which yields counts of observable behaviors, antecedents, and consequences. The function of behavior is not always clear, however. Classrooms and

21 6 playgrounds contain many antecedents and consequences that exercise no control over stereotypical behavior. Moreover, sorting through the conditional probabilities that emerge from descriptive assessments to identify a function is cumbersome and timeconsuming. Still, when stereotypical behavior occurs regularly and repeatedly throughout observation periods and across a variety of settings and people, it is safe to assume that the behavior is automatically reinforced. Functional Analysis. The third type of assessment is called an experimental or functional analysis (FA) (Iwata, Dorsey, Slifer, Bauman & Richman, 1982/1994). An FA involves direct observation and measurement of behavior under controlled conditions. These conditions are deliberately created to identify the response-reinforcer relationship. This is done by comparing measures obtained during observations across four reinforcement conditions: social negative reinforcement, social positive reinforcement, automatic negative reinforcement, and automatic positive reinforcement. The condition in which the measures show a consistent slope, trend, and level is identified as the functional reinforcement condition. When vocal stereotypy occurs during the social negative reinforcement condition and not during any other condition, for instance, the conclusion would be that the behavior is reinforced by escape from some person, demand, or instruction. For this case, an intervention would be developed to modify the escape-maintained behavior. The condition in which an automatic reinforcement function is ordinarily found occurs in what is called the alone condition. A child is literally left alone to behave as s/he sees fit. When the target behavior occurs most frequently in this condition compared to the other conditions, an automatic function is suspected.

22 7 How automatic reinforcement is more specifically determined centers on visual inspection of the data. Three criteria are employed. Occurrences of the target behavior in the alone condition, as mentioned above must be highest compared to the other conditions, especially a play condition, which involves access to tangible stimuli and non-contingent attention. The second criterion is that the target behavior must also occur throughout an extended alone condition, this involving an additional ignore session where the participant is once again left alone. The third criterion is that the behavior must be most frequent under less socially stimulating conditions (alone, attention, and tangible conditions) and less frequent under more socially stimulating conditions (demand and play) (Hagopian, Fisher, Thompson, Owen-DeSchryver, Iwata & Wacker, 1997; Roane, Fisher, Kelley, Mevers & Bouxsein, 2013). By following these criteria, however, it is still possible to make the mistake of identifying stereotypical behaviors as automatically reinforced and then compounding this mistake by developing a treatment based upon on erroneous function. Specific Assessments and Analyses for Motor and Vocal Stereotypy Kennedy (2000), Miltenberger (2000), and Carr (2000) provide some additional evidence for determining whether or not stereotypy is automatically reinforced after an initial FA. Kennedy suggests identifying idiosyncratic or contrived reinforcers, the specific sources of public or private stimulation, and any possible source of competing stimulation when assessments do not produce clear and conclusive results. Miltenberger recommends including an analysis of within-session behavior patterns, identifying the response class hierarchies, and evaluating biological events that could serve as motivational operations. Taking a different approach, Carr suggests that the selection of

23 8 FA conditions be based on the individual conditions under which behaviors occur rather than a one-size-fits-all approach. Taken together, these suggestions can help guide the FA process when an automatic function is suspected but not confirmed. Very few investigators actually assess stereotypical behaviors with this kind of rigorous analysis. Pyles, Riordan, & Bailey (1997) created a descriptive assessment entitled the Stereotypy Analysis to examine variables in the social environment (e.g., demands, attention) that correlate with stereotypical behaviors. Specific variables (e.g., activities, demands) in the social environment that occasioned stereotypy were identified by Pyles et al. for three of their five participants. Treatments for the three participants involved providing activities, controlling demands, reinforcing alternative behaviors, and blocking and redirecting stereotypical responses. All treatments effectively decreased stereotypy. Kennedy, Meyer, Knowles, & Shukla (2000) analyzed the functions of motor stereotypy for five children with autism. An FA revealed that, for four participants, stereotypy was maintained by automatic reinforcement. For the fifth participant, motor stereotypy was maintained by both negative and automatic reinforcement. Treatment for this participant involved teaching the child to request items, which decreased stereotypy to near-zero levels. Contrucci-Kuhn & Triggs (2009), in another study, analyzed social variables when an FA indicated that the self-injurious behavior (SIB) of a seven-year-old child was automatically reinforced. Contrucci-Kuhn & Triggs showed that the child s SIB was not automatically reinforced, as was originally claimed, but was instead maintained by positive reinforcement in the form of attention.

24 9 More comprehensive assessment for stereotypical behavior has led to developing treatments that are better aligned with the assessment. These assessments are not as refined as those conducted with non-stereotypical behaviors, however. A question as to how precise assessments for non-stereotypical behaviors might contribute to the evaluation and understanding of the conditions under which stereotypical behaviors occur remains unanswered. Conditional Analyses for Non-Stereotypical Behaviors When behavior is assumed to be maintained by social negative reinforcement, for instance, what is being stated is that the behavior occurs because it escapes a demand. Little information is ordinarily provided, however, on the types of demands that could reinforce the escape behavior. The same can be said about the relative preference for both tangible stimuli and social attention. A systematic analysis of these types of variables within an FA as to how they may affect motor and vocal stereotypies is needed. How analyses of these sorts of variables occur with non-stereotypical behaviors is the focus of the next section. Negative Reinforcement Analyses. When assessing whether or not behavior is maintained by negative reinforcement, demands are often selected from individual education plans or home treatment programs. The assumption is that if an individual engages in problem behavior, it is probably maintained by negative reinforcement in the form of escape from instructions or demands. It is possible that there are certain aspects of the demand or demand sequence that maintain problem behavior. For instance, when asking a child to point to a picture of a dog, it may be the case that the child has not yet learned what a dog is or has a poor rapport with the person asking the question. The

25 10 function may be to escape from the demand in the first case, while in the second case; the function may be to escape from the person asking the question. While the overall function of behavior would be negative reinforcement, a standard functional analysis would not identify that aspect of the situation that actually reinforced the problem behavior. Several researchers have addressed this issue, particularly with regard to task difficultly in the context of demands. Roscoe, Rooker, Pence, & Longworth (2009) evaluated the use of a demand assessment to determine which tasks to utilize in a functional analysis for four individuals with disabilities. The assessment was conducted with 12 demands from a variety of skill areas to determine task difficulty. These demands were categorized as demands completed and demands not completed and were utilized in the demand condition of a functional analysis. Results for all participants indicated that task difficulty affected the rates of problematic behavior, with difficult demands producing more frequent occurrences than easy demands. Thus indicating that the difficulty level of demands can influence problem behavior. Positive Reinforcement Analyses: Tangibles. When determining whether or not the function of behavior is maintained by positive reinforcement in the form of access to tangibles (toys, tablets), items are selected based on information from parents or from stimulus preference assessments. It is possible, however, that parents cannot accurately identify the types of tangibles their child prefers. Further, the child may not engage in problem behavior in the presence of the highest preferred item from a preference assessment. If a child refrains from hitting a playmate in the presence of a highly

26 11 preferred toy, for instance, but not in the presence of a moderately preferred toy, then using a highly preferred item in a functional analysis would be unrevealing. Researchers are beginning to address this problem with the tangible condition of the standard FA. Mueller, Wilczynski, Moore, Fusilier & Trahant (2001) manipulated the types of stimuli available to an eight-year old boy diagnosed with autism after an initial FA noted that aggression was maintained by access to tangible items. Specifically, the authors conducted an analysis of highly preferred, moderately preferred, and least preferred toys to determine the extent to which access to the items effected aggression. Results indicated that behaviors occurred more often when highly preferred items were restricted. This indicated that the types of items in an FA could influence levels of behavior. Positive Reinforcement Analyses: Attention. When evaluating whether or not the reinforcement function of behavior is attention, more than one form of attention is typically provided during an FA, including, brief physical contact, social disproval, and a statement of concern. The assumption is that if the participant engages in the target behavior under these conditions, it is most likely maintained by attention. Some participants may be more or less sensitive to certain forms of attention, however, and several researchers have studied this issue by varying the type of attention. Kodak, Northup, & Kelley (2007), for example, evaluated the effects of six types of attention on aggression, disruption, and inappropriate vocalizations displayed by two children. Results indicated problem behavior occurred when certain forms of attention were provided and did not occur with other types of attention. Refinements to the

27 12 attention condition in an FA, according to Kodak and her colleagues, are necessary to determine the actual function of behavior. Reinforcement Analyses for Motor and Vocal Stereotypy When it comes to assessing the conditions of FAs, researchers are investigating task difficulty levels, how different types of tangible stimuli influence behavior, and how forms of attention affect behavior. These analyses are conducted to ensure that the response-reinforcer relationship identified during the FA is accurate. There is no such literature on conducting refined analyses with nominally automatically reinforced, motor and/or vocal stereotypy, however. Instead, the literature on motor and vocal stereotypy generally concludes that these behaviors are automatically reinforced (DiGennaro-Redd, Hurst & Hyman, 2012). On this conclusion, treatments for stereotypical behaviors include reinforcer substitution (e.g., playing with shaving cream) to applying sensory extinction (e.g., placing gloves on someone). It is often the case, too, that the terms stereotypical and automatic are used interchangeably in the literature. By using refined methods similar to the analyses mentioned above, it should be possible to isolate social variables that may function as reinforcers for stereotypical behaviors. The purpose of this study is to systematically analyze those variables that might contribute to the maintenance of motor and/or vocal stereotypy when initial functional analyses indicates that the behaviors are automatically reinforced. Specifically, analyses were conducted for different categories of demands and tangible stimuli as well as different forms of attention to determine their respective effects as reinforcements for motor, vocal, and motor/vocal stereotypy.

28 13 Methodology Participants and Settings The participants in this study each met the following inclusion criteria: (1) a diagnosis of autism, (2) no visual or physical impairments, (3) between the ages of 4 and 15, (4) a documented history of engaging in a motor, vocal, or motor and vocal stereotypical behavior, and (5) stereotypical behavior was assumed to be automatically reinforced. Seven individuals participated in this study. One participant engaged in motor stereotypy, one participant engaged in vocal stereotypy, two participants engaged in motor and vocal stereotypy, and three participants engaged in a combination of motor and vocal stereotypy. Each child participated in the three experiments. Participant 1(P1) was a 9-year-old boy who engaged in a combination of motor and vocal stereotypy. His stereotypical behaviors consisted of high pitched/random vocalizations, rocking back and forth, and waving his fingers in an up and down motion in his face. P1 was able to communicate his wants and needs via a communication device using 1-2 words. He rarely spoke to individuals without prompting and was in a selfcontained classroom with inclusion in the typical education classroom during snack time, lunch, recess, library, and music. Participant 2 (P2) was a 14 year-old-boy who engaged in a combination of motor and vocal stereotypy. His targeted behaviors consisted of repeating sounds and phrases and body pressing. P2 was able to communicate verbally-vocally and he was fully included in his regular classroom setting with minimal support from an aide.

29 14 Participant 3 (P3) was a 10-year-old boy who engaged in a combination of motor and vocal stereotypy. His stereotypical behaviors consisted of repeating sounds and phrases and body pressing. P3 was able to communicate his wants and needs via a communication device using 1-2 words. He spoke to individuals without prompting when he wanted items and was in a self-contained classroom with inclusion in the typical education classroom during lunch, recess, library, and music. Participant 4 (P4) was a 13-year-old boy who engaged vocal stereotypy defined as repeating sounds and phrases. He was able to communicate his wants and needs verballyvocally and spoke to individuals with minimal prompting. P4 was in a special education classroom for academic support and participated in a regular education classroom for lunch, recess, physical education, library, and music. Participant 5 (P5) was a 13-year-old boy who engaged motor stereotypy defined as body pressing. He was able to communicate his wants and needs verbally-vocally and spoke to individuals with minimal prompting. P5 was in a special education classroom for academic support and participated in a regular education classroom for lunch, recess, physical education, library, and music. Participant 6 was an 11-year-old-boy who engaged in both motor and vocal stereotypy separately. These two stereotypies were assessed individually: motor (P6a) and vocal (P6b). His motor stereotypy was defined as body pressing and vocal stereotypy was defined as repeating sounds and phrases. P6 was able to communicate with others using 5-7 word sentences. He was in a self-contained classroom and was interacted with his typically developing peers during lunch and recess.

30 15 Participant 7 was a 6-year-old boy who engaged in both motor and vocal stereotypy separately. These two stereotypies were assessed individually: motor (P7a) and vocal (P7b). His motor stereotypy was defined as waving his fingers/hands and rocking back and forth. Vocal stereotypy was defined as repeating sounds. P7 was able to communicate with others using 3-7 word sentences via a communication device and was not verbal-vocal. He was in a self-contained classroom and interacted with his typically developing peers during lunch, recess, and computer time. Sessions were conducted in a room at the participant s home. The session area contained, at a minimum, a table, chairs, and materials relevant to each session. Access to items that could not be removed was restricted. Behavior Definitions Targeted behaviors were motor stereotypy, vocal stereotypy, or a combination of motor and vocal stereotypy. Motor stereotypy was defined as engaging in consistent body movements with no apparent adaptive significance (e.g., moving fingers in front of eyes or rocking back and forth). Vocal stereotypy defined as emitting sounds or words that did pertain to the given task (e.g., repeating phrases from a television show or uttering random sounds). Table 1 lists the more specific definitions for each stereotypical behavior shown by each of the seven participants. Data Collection & Response Measurement Data were collected via laptops with the iobserve data collection system. The proportions of 10-s intervals in which stereotypies occurred were collected via a partialinterval recording method. Data were collected from videotaped sessions.

31 16 Interobserver Agreement Interobserver agreement (IOA) data were collected by an independent, second observer for 35% of all sessions. To assess agreement, sessions were divided into 10-s consecutive intervals. An agreement was defined when both observers scored the same response as occurring in an interval. A disagreement was defined as observers scoring different responses in an interval. IOA was calculated by dividing the number of agreement intervals by the number of agreement plus disagreement intervals and then multiplying by 100%. An IOA value of 96% was achieved, with a range of 90% to 100%. Procedural Integrity Procedural integrity (PI) data were collected for 50% of all sessions via the iobserve program. To assess PI, sessions were divided into 10-s consecutive intervals. A correct was defined when the experimenter followed the outline of the session without making an error during an interval. To illustrate, if a child engaged in stereotypy after the presentation of a demand, the experimenter removed demands for 30s. An incorrect would be defined as the experimenter not removing the demands for 30s. Similarly, if the experimenter prompted the child to complete a demand before 30s has elapsed, an incorrect would be scored. Procedural integrity was calculated by dividing the number of correct intervals by the number of correct plus incorrect intervals and then multiplying by 100%. A PI value of 95% was obtained (range: 95% to 100%). Functional Behavior Assessment To gather basic information about the participant and their stereotypical behavior, a child s parents completed the Functional Assessment Screening Tool-Revised (Iwata, DeLeon & Rosco, 2013). The purpose of the FAST-R was three-fold: 1) to determine if

32 17 the assumed function was to access automatic reinforcement, 2) to establish whether a tangible condition should be included in the FA, and 3) to select which item should be used in the tangible condition. Functional Analysis A functional analysis, based on the one described by Iwata et al., 1982/1994, was conducted with all participants for each stereotypical behavior. Instead of a traditional alone condition, however, an ignore condition was conducted for the simple reason that it seemed inappropriate to leave a child alone in a room without supervision. All parents indicated that stereotypical behavior appeared to occur to gain access to a specific item(s). A tangible condition was thus included in the FA. Previous research on session duration has found that similar results occur with 10 and 15 min FA session lengths (Wallace & Iwata, 1999). Based on this research, sessions were 10 min in length. To enhance the participants discrimination between each condition, the experimenter wore a different colored shirt that correlated with each FA condition (see Conners, Iwata, Kahng, Hanley, Worsdell, & Thompson, 2000). Specifically, a white shirt was worn during the ignore condition, a black shirt during the tangible condition, a green shirt during the attention condition, a red shirt during the play condition, and a yellow shirt during the demand condition. In addition to wearing different colored shirts during each condition, a fixed cycle of condition presentations was implemented to control for potential sequence effects that can occur with an FA (see Hammond, Iwata, Rooker, Fritz, & Bloom, 2013). During an ignore condition, for instance, participants do not receive attention, which may alter the effects of attention in later conditions. In the light of these considerations, the order of

33 18 conditions for the FAs in the present study was ignore, attention, tangible, play, and - demand. One set of FA conditions was conducted one to three times per day until the function of behavior was determined. Each condition was a separate session, and no more than 50 sessions were conducted with a participant. A three-to-five minute break occurred between each FA session when multiple sessions were conducted in a given day. Ignore Condition. This condition served as one test for automatic reinforcement. The experimenter and the participant were seated no more than two feet away from each other. The session began when the child and experimenter were sitting at a table. The child was free to move about the room once the session began. All behaviors were ignored. Extended ignore sessions were conducted once the data indicated that stereotypy was automatically reinforced. Attention Condition. The attention condition served as a test for social, positive reinforcement, in the form of attention. During this condition, the experimenter and the participant sat at a table no more than two feet away from each other. When seated, the experimenter said, You have some toys to play with while I complete some work as they directed the child to the toys. The experimenter pretended to be busy, leaving the child to play with the toys or move about the room. Contingent on the occurrence of stereotypy, a statement of concern was provided (e.g., I don t like it when you flap your hands ; people may not like it when you talk to yourself ), together with a reprimand (e.g., don t say things like that ; don t flap your hands ), and brief physical contact (e.g., touching the arm or rubbing the back).

34 19 Tangible Condition. The tangible condition serves as a test for social, positive reinforcement, in the form of tangibles. During this condition, the experimenter and the participant were at a table no more than two feet away from each other. Prior to the tangible condition, the participant was given 120s access to the item that the parents indicated was preferred from the FAST-R. The session began after the FT 120s elapsed and after the item was removed. Contingent on the occurrence of stereotypy, the item was returned to the child for 30s. After this period, the item was removed until stereotypy occurred again and so forth throughout the session. Demand Condition. The demand condition serves as a test for social, negative reinforcement in the form of escape from demands. Tasks for the demand condition included educational activities or daily living skills and were selected from child s individual education placement goals or home therapy program. During this condition, the child and experimenter were seated at a table. Session began with the first presentation of a demand. Demands were presented continuously until stereotypy occurred. When the participant complied with a demand within 3-5s, vocal praise (e.g., That s the right answer ; Good job! ) was given. If the participant did not comply with the demand within 3-5s, a three-step prompting hierarchy was implemented as follows: (1) the initial demand (e.g., Touch the dog ; Wipe your nose ); (2) how to complete the demand was modeled while repeating the demand, and (3) physically guiding the participant to comply with the demand while repeating the demand. When the demand was verbal-vocal, however, the prompting hierarchy included (1) the initial demand (e.g., Say dog ; Say blue ), (2) providing a partial verbal-vocal prompt after repeating the demand (e.g., Say dog d or Say blue bl ), and (3) supplying the full verbal-vocal

35 20 prompt after repeating the demand (e.g., say dog dog, say blue blue ). Contingent on stereotypy, the participant was given a 30s break from demands. Specifically, the experimenter said, Ok, you don t have to or You don t have to and then removed the demand and turned away. After the break, a different demand was presented. Play Condition. The play condition serves as a control for the four conditions. During this condition, participants were given unrestricted access to leisure items. Attention was delivered every 30s and noncontingently throughout this condition, and no demands or instructions were provided. The experimenter and the participant were no more than two feet away from each other. The session began by the experimenter directing the participant toward objects on the table while saying to the child, Here are some toys if you would like to play. Social praise (e.g., Great job playing ; That is cool ) and physical contact (e.g., patting the back, touching the arm) were delivered according to a FT 30s schedule. All of a child s initiations to interact with the experimenter were reciprocated, however all stereotypical behaviors were ignored. Experimental Design & Interpreting Functional Analytic Data A multielement, single subject design was used in this study. Data were visually analyzed based on trend, slope and variability of the data. Stereotypical behaviors were determined to be automatically reinforced when one of the following criteria were met: 1) data, proportion of intervals, in the ignore condition were higher than other conditions 2) data were high for all conditions and throughout the extended ignore sessions, or 3) data were highest in conditions with low social

36 21 stimulation (alone, attention, and tangible conditions) and lowest in conditions with comparably higher social stimulation (demand and play). Experiment I: Demand Analysis The purpose of Experiment I was to determine the degree to which motor, vocal, or motor and vocal stereotypy was maintained by negative reinforcement in the form of escape from a specific demand(s). To pursue this hypothesis, a Demand Assessment was conducted with participants to determine task difficulty level. This was done for each demand rather than each skill set as tasks from the same skill set can vary in difficultly. For the Demand Assessment, data were collected on the prompt level (from a three-step prompting hierarchy) necessary for the participant to comply with each task. This prompting hierarchy was the same one used in the demand condition of the FA. To make certain that the most accurate data on difficulty could be gathered, each demand was assessed two to three times. The Demand Assessment was conducted until there were 20 demands in each category. Once the difficulty level for the task was ascertained, it was placed in one of three categories: easy, moderately difficult, and difficult. Easy. A demand was easy if the participant readily completed the demand without prompting for two of three presentations. Moderately Difficult. A demand was moderately difficult if the participant was prompted to complete the demand with the second prompt of the prompting hierarchy for two of three presentations. Difficult. A demand was difficult if the participant was fully prompted to complete the demand for two of three presentations.

37 22 A Demand Analysis (DA) was conducted after the Demand Assessment. All conditions were the same as to the demand condition of the FA with this exception: the demands presented were based on difficulty level (easy, moderately difficult, and difficult conditions). Sixty demands (20 demands per difficultly level) were utilized for the DA for each participant. Sessions of each demand level were conducted in random order. One set of three DA conditions was conducted three to five times per day until it was determined that demand difficulty and stereotypy were functionally related. Each condition was considered a separate session, and no more than 50 sessions were conducted with one participant. Breaks lasting 3-5 minutes were provided when multiple sessions were conducted on a given day. Treatment Protocol: Participant 1. The DA for Participant 1 shows that stereotypy occurred less often with easy demands and most often with difficult demands (see Figure 10). Treatment for this child involved conducting a baseline with the easy condition in which stereotypy occurred the least. After baseline, easy demands were gradually withdrawn while moderately difficult tasks were gradually introduced. Fading from easy to moderately difficult tasks occurred in four phases, as follows: 15 easy/5 moderately difficult tasks, 10 easy/10 moderately difficult tasks, 5 easy/15 moderately difficult tasks, and 20 moderately difficult tasks. The criteria for moving from one phase to the next included a downward trend in stereotypy, which leveled off at or below baseline levels. After fading the moderately difficult tasks into the session, a midtreatment DA was conducted. Once the mid-treatment DA was completed, moderately difficult tasks were removed and difficult tasks were introduced in these four phases: 15 moderately

38 23 difficult/5 difficult tasks, 10 moderately difficult/10 difficult tasks, 10 moderately difficult/15 difficult tasks, and 20 difficult tasks. The criteria for moving from one phase to the next included a downward trend in the data, which leveled off at or below baseline levels of stereotypy. A post-treatment DA was conducted once the demand fading for difficult tasks was completed. Experiment II: Tangible Analysis The purpose of Experiment II was to determine the degree to which motor, vocal, or motor and vocal stereotypy was maintained by social, positive reinforcement in the form of access to specific tangible items. To pursue this hypothesis, a paired-choice preference assessment (see Fisher Piazza, Bowman, Hagopian, Owens & Slevin, 1992) was conducted with each participant prior to the Tangible Analysis (TA) conditions. The child s parent selected seven to eight leisure items for assessment. These included items that involved playing simple turn taking games, listening to music and/or sounds, light-up toys, and manipulatives (e.g., cars, action figures). Participants were given access to all of the items prior to each assessment to confirm that they interacted properly with each item. This involved the experimenter watching the child play with the leisure item for 45-60s. The preference assessment began when the participant was given a choice between playing with one of two items. Each item was paired with every other item in the assessment one time. When a participant selected an item by vocally identifying, pointing to, or reaching for it, s/he was given the item for 45-60s. All participants selected one item each time two items were presented.

39 24 Data were collected on which item the participant selected in a presented pair. A rank order of preference was calculated by dividing the number of times an item was selected by the number of times the item was presented and multiplying by 100%. The items were then ordered from the highest percentage to the lowest. This hierarchy data was used to determine the preference level of all items. Preference levels of items were placed in three categories: preferred, moderately preferred, and non-preferred. Preferred Stimulus. An item was preferred when it was selected % of the presentations. Moderately Preferred Stimulus. An item was moderately preferred when it was selected 60-70% of presentations. Non-Preferred Stimulus. An item was non-preferred when it was selected 0-20% of the presentations. The TA was conducted after the preference assessments were complete. All conditions were the same as the tangible condition of the FA with this exception: the items presented were based on preference level (preferred, moderately preferred, and non-preferred). Conditions were conducted in random order. One set of three TA conditions were conducted three to five times per day until it was determined that item preference and stereotypy were functionally related. No more than 50 sessions were conducted with one participant. Participants had a 3-5 minute break between each session when multiple sessions were conducted in a given day. Treatment Protocol: Participant 6a. The TA for participant 6a shows that stereotypy occurred most often with the least preferred toy and least often with the most preferred item (see Figure 36). Treatment involved baseline and a differential

40 25 reinforcement of other behavior (DRO) procedure. During baseline, contingent on motor stereotypy, the least preferred tangible item was presented for 30s. The DRO procedure involved providing access to the highly preferred tangible item for 15s when motor stereotypy did not occur in the presence of the least preferred item for a given period. This period of time was gradually increased across the following eight phases: 5s, 10s, 20s, 40s, 80s, 160s, 320s, and 600s. The criteria for moving from one phase to the next included a downward trend in the data, which leveled off at or below baseline levels of stereotypy. A post-treatment TA was conducted once the 600s phase was completed. Experiment III: Attention Analysis The purpose of Experiment III was to determine the extent to which motor, vocal, and motor and vocal stereotypy was maintained by social, positive reinforcement in the form of certain types of attention. To pursue this hypothesis, an Attention Analysis (AA) was conducted after the FA was completed. Three forms of attention occurred, as follows: physical attention, statements of concern, and mild verbal reprimands. Each one of these forms of attention were assessed separately for each participant. Physical Attention. Physical attention involved brief physical touch contingent on stereotypy (e.g., touching the back or shoulder). Statements of Concern. Statements of concern involved expressing unease over the stereotypic behavior (e.g., I don t like it when you flap your hands ; People may not like it when you talk to yourself ). Mild Verbal Reprimands. Mild verbal reprimands involved providing vocal statements admonishing the participant for engaging in stereotypy (e.g., Stop talking to yourself ; Don t flap your hands ).

41 26 All conditions for the AA were conducted as the attention condition of the FA with this exception: the type of attention presented varied (physical attention, statements of concern, and mild verbal reprimand). Conditions were conducted in random order. One set of three, AA conditions was conducted three to five times per day until it was determined that different types of attention and stereotypy were functionally related. No more than 50 sessions were conducted with one participant. Participants had a break for 3-5 minutes between each session. Treatment Protocol: Participant 6b. The AA data for Participant 6b showed that his vocal stereotypy occurred most often during the statement of concern and physical touch conditions. Vocal stereotypy showed a downward trend in the reprimand condition and, therefore, a treatment was not warranted. Treatment for this participant centered in a DRO contingency involving statements of concern contingent on the absence vocal stereotypy, physical touch condition, and differential reinforcement of physical touch in the absence of vocal stereotypy. During Phase 1, contingent on vocal stereotypy, statements of concern were provided. The DRO procedure (Phase 2) involved providing statements related to appropriate talking or not engaging in vocal stereotypy (e.g., being quiet, talking about something relevant, and so on). When vocal stereotypy fell at or below the levels in Phase 1, Phase 3 began. This phase involved physical touch being provided contingent on vocal stereotypy. When behaviors showed an increasing trend, a DRO procedure for physical touch (Phase 4) was implemented. This phase involved physical touch contingent on either appropriate talking or the absence of vocal stereotypy. The criteria

42 27 for moving from one phase to the next included a downward trend in the data. A posttreatment AA was conducted once the phases were completed. Results Functional Behavior Assessment The demographic characteristics and behavior definitions for each participant are provided in Table 1. The age range for participants was 6-14 years. All were males, diagnosed with autism, and who did not have any other disabilities or impairments. The parents responses on the FAST-R (see Appendix A) indicated that the behaviors of concern were motor stereotypy for participants 5 (P5), 6a (P6a), and 7a (P7a), vocal stereotypy for participants 4 (P4), 6b (P6b), and 7b (P7b), and motor and vocal stereotypy for participants 1, (P1), 2 (P2), and 3 (P3). Via the FAST-R, parents for all participants indicated that they believed their child s stereotypical behaviors were maintained by automatic reinforcement (see Table 2) and that all participants engaged in stereotypy to access tangible items. Functional Analysis The exact items utilized during the functional analyses are listed in Table 3. The FA results, in general, indicated that stereotypical behaviors, for all participants, were automatically reinforced (see Figures 1-9). Specifically, all participants data, except P6b (Figure 7) and P7a (Figure 8), met the criteria for stability, with no trends or level changes and occurring throughout the extended ignore sessions (Hagopian et al., 1997; Roane et al., 2013). Data for P6b and P7a demonstrate a trend in that stereotypical behaviors are increasing throughout the assessment. Upon closer examination of the data, however, P6b and P7a engaged in stereotypy for access to the reinforcer and did not

43 28 engage in the behavior during the reinforcement interval in the beginning of the analysis. As the analysis continued, the children began to engage in stereotypical behavior throughout the reinforcement intervals. Experiment I: Demand Analysis All participants took part in the DA. Prior to the analysis, a Demand Assessment (see Appendix B) was conducted with each participant to determine difficultly of tasks (i.e., easy, moderately difficult, or difficult). The specific demands utilized throughout the DA are presented in tables 4-12 for participants 1-7b, respectively. The DA results for participants 1-7b are presented in Figures 10-18, separately. Specifically, these results suggest that P6a, P6b, and P7a, (Figures 15-17, respectively) engaged in more stereotypical behaviors when presented with difficult demands compared to easy or moderately difficult demands. Note that P6a and P6b are the same participant and that he engaged in both motor and vocal stereotypy, which did not occur in conjunction. The DA for both motor and vocal stereotypy demonstrate a similar trend. Higher levels of behavior in the difficult condition and a downward trend in stereotypy for the moderately difficult and easy conditions. P2 (Figure 11) and P7b (Figure 18) showed the most stereotypy when presented with moderately difficult demands. In addition, data for the easy condition was in between the other conditions, demonstrating an upward trend. While levels of behavior during the difficult condition were low. P7b s data indicate levels of vocal stereotypy during the moderately difficult condition to be increasing stereotypical behaviors during the easy and difficult conditions demonstrate a downward trend.

44 29 P3 s motor and vocal stereotypy (Figure 12) occurred most often when presented with easy and moderately difficult demands relative to difficult demands. In contrast, P1 (Figure 10), P4 (Figure 13), and P5 (Figure 14) emitted more stereotypical behaviors when given difficult and moderately difficult demands relative to easy demands. Both P4 and P5 s data indicate that levels of behavior during the moderately difficult and difficult conditions increased. P4 s data show an increase in vocal behavior in both the difficult condition and the moderately difficult condition. Stereotypy for P4 during the easy condition remained low. Behavior for P5 increased during the moderately difficult condition and during the difficult condition. The data for P1 shows that levels of motor and vocal stereotypy were high for the difficult condition, increasing for the moderately difficult condition, and low for the easy condition. These data indicate that the function of stereotypy is influenced by the difficulty of demands and the behavior is partially maintained by social negative reinforcement in the form of escape from certain types of demands. Treatment: Participant 1. Figure 19 shows the treatment data for P1. Since P1 s DA demonstrated that he engaged in more motor and vocal stereotypy during the difficult condition followed by the moderately difficult condition and then the easy condition, a demand fading procedure was utilized to gradually increase the difficult level of demands. The first Panel of Figure 19 are the baseline data of motor and vocal stereotypy. Once baseline levels were established, fading out the easy demands and fading in the moderately difficult demands began. These data are presented in Panels 2-5 of Figure 19. The data for 15 easy demands and 5 moderately difficult demands (Panel 2) shows a downward trend, below baseline levels. With the introduction of 10 easy and 10

45 30 moderately difficult demands (Panel 3), the levels of behavior continued to decrease. (It is important to note that after the fourth session in Panel 3 the child was sick for two weeks. Even though the data demonstrated a downward trend, a reestablishment of behavior levels was conducted and motor and vocal stereotypy continued to decrease.) The behavior levels in Panel 4 indicate that stereotypy remained low when the demands changed to 5 easy and 15 moderately difficult. When 20 moderately difficult demands (Panel 5) were utilized during sessions, levels of behavior remained low. Mid-treatment DA data for P1 are depicted in Figure 20 and indicated that the function of motor and vocal stereotypy changed from the initial DA. Specifically, the proportion of stereotypy with difficult demands decreased as did behaviors during the moderately difficult condition. After the mid-treatment DA, demand fading for difficult demands began. These data are presented in Figure 20, Panels 6-9. Data for 15 moderately difficult demands and 5 difficult demands (Panel 6) indicate that this was the longest phase of treatment. Viewing Panel 6, the data remained generally lower than baseline levels. These data also demonstrate a downward trend after 10 sessions of unstable data. When fading involved 10 moderately difficult and 10 difficult demands (Panel 7), the proportion of behavior dropped and decreased further with 5 moderately difficult demands and 10 difficult demands (Panel 8). Finally, levels of motor and vocal stereotypy were at zero levels when 20 difficult demands were introduced (Panel 9). A post-treatment DA was conducted at the conclusion of treatment. These data are presented in Figure 21. Data indicate that the proportion of motor and vocal stereotypy for P1 remained generally low.

46 31 Experiment II: Tangible Analysis Figures depict the preference assessment outcomes for Participants 1-7b, respectively. Data for Participants 1-7b of the Tangible Analysis (TA) are presented in Figures 31-39, separately. For all participants, Table 13 outlines the specific leisure items utilized for the TA conditions. The data for P2 (Figure 32) and P7a (Figure 38) indicate that stereotypy was highest for the TA conditions with the least preferred items and lowest with the moderately preferred items. P1 s data (Figure 31) for the TA show that motor and vocal stereotypy was most frequent during the highly preferred condition and lest frequent during the moderately preferred and least preferred conditions. In contrast, P7b s (Figure 39) data indicated that the different types of tangible items did not influence vocal stereotypy. This is evident, as the levels of behavior were relatively equal during all conditions. Data for P5 (Figure 35) and P6b (Figure 37) were consistent in that stereotypy was highest during the moderately preferred and least preferred conditions. For P5, levels of motor stereotypy increased in the moderately preferred condition and remained consistent during for the least preferred condition. Stereotypy for P5 decreased in the highly preferred condition. P6b s data show that vocal stereotypy increased the most during the least preferred condition and remained steady during with the highly preferred condition. The TA data for P3 (Figure 33) indicate that motor and vocal stereotypy increased during the least preferred condition and highly preferred condition. Levels of stereotypy were comparably lower for the moderately preferred condition.

47 32 Data obtained on stereotypy for P4 (Figure 34) and P6a (Figure 36) showed that levels of behavior were highest during the least preferred condition and lowest during the highly preferred condition. Stereotypy during the moderately preferred condition ranged between these two conditions. The data for P6a indicated that motor stereotypy most often occurred during the least preferred condition and occurred less often during the highly preferred condition. Treatment: Participant 6a. A treatment was implemented with P6a whose data are and is presented in Figure 40. The first Panel show baseline data on the proportion of motor stereotypy obtained during the least preferred condition. Panels 2-9 depicts data for the DRO treatment, which involved a DRO 15s of access to the highly preferred item contingent on the absence of motor stereotypy with the least preferred item for a specified period of time. Panel 2 shows the results of the 5s time requirement where stereotypy decreased. When the time requirement increased to 10s (Panel 3), levels of stereotypy increased but eventually trended downward after the fourth treatment session. With the time increased to 20s (Panel 4) the level of behavior decreased. Further decreases were obtained when the time increased to 40s (Panel 5) and when it increased to 80s (Panel 6).When the requirement increased to 160s (Panel 7) stereotypy remained low. The data for the 320s time requirement (Panel 8) and for the 600s (Panel 9) requirement remained low as well. A post-treatment TA was conducted with P6a to determine how the treatment may have changed the function of motor stereotypy relative to the types of tangible stimuli presented. The data shown in Figure 41 indicate that levels of motor stereotypy were low across all conditions.

48 33 Experiment III: Attention Analysis The AA data for Participants 1-7b are presented in Figures The data for P7a (Figure 49) indicate that motor stereotypy was highest during the reprimand condition. Stereotypy during the physical touch and statement of concern conditions each were lower. For P4 (Figure 45), levels of vocal stereotypy were highest during the reprimand and physical touch conditions and lowest during the statement of concern condition. The proportion of P4 s vocal stereotypy decreased during the statement of concern condition. The data for P3 (Figure 44) indicate motor and vocal stereotypy were highest for the statement of concern condition, increased during the physical touch condition, and remained comparably low during the reprimand condition. The AA data for P1 and P5 shown in Figures 42 & 46, respectively, indicate that stereotypical behaviors occurred most often during the statement of concern condition and least often during the physical touch condition. In contrast, the data sets for P2, P6a, P6b, and P7b (Figures 43, 47, 48, and 50, respectively) each show a common theme: stereotypical behaviors were highest during the physical touch condition, lowest during the reprimand condition, and intermediate during the statement of concern condition. The first six sessions of the AA for P2 (Figure 43) did not produce a differentiation in motor and vocal stereotypy. After the six initial sessions, however, stereotypy began to separate, suggesting that for P2, the type of attention was affecting stereotypy, with physical touch producing the most stereotypy and reprimands producing the least.

49 34 The AA data for P6b (Figure 48) indicated that vocal stereotypy was highest during the physical touch condition, and lowest during the reprimand condition. Treatment: Participant 6b. A treatment involving either reinforcing talking appropriately or the absence of vocal stereotypy was implemented with P6b and is presented in Figure 51. The data in Panel 1 show that stereotypy was greatest during the statement of concern condition. When reinforcement was contingent on appropriate talking and/or not engaging in vocal stereotypy (Panel 2), stereotypy decreased. Panel 3 shows an increase in behavior when physical attention was contingent on vocal stereotypy. When physical attention was contingent on appropriate talking and/or the absence of vocal stereotypy (Panel 4), the target behavior decreased. A post-treatment AA (see Figure 52) indicated that the levels of vocal stereotypy change after treatment. Specifically, physical touch contingent on vocal stereotypy increased. While behavior during the statement of concern condition and reprimand condition remained steady. Discussion Motor and vocal stereotypical behaviors are common with individuals diagnosed with autism and developmental delays (DiGennaro-Reed, Hirst & Hyman, 2012). The function of these behaviors is typically automatic reinforcement (DiGennaro-Reed, Hirst & Hyman, 2010; Hanley, Iwata, McCord, 2003; Rapp & Vollmer, 2005). However, researchers are discovering that motor and vocal stereotypy can be maintained by social contingencies (Cunningham & Schriebman, 2008; Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994; Kennedy, Meyer, Knowles, & Shukla, 2000; Wilke, Tarbox, Dixon, Kenzer, Bishop, & Kalavand, 2012). However, a systematic method for assessing

50 35 the extent to which social reinforcers influence motor and vocal stereotypies does not exist. As a result, the purpose of this study was to conduct systematic analyses of social variables that could contribute to the reinforcement of motor and/or vocal stereotypy. These analyses were conducted when initial FAs indicated that the behaviors were automatically reinforced. By utilizing information from refined conditional assessment procedures conducted for non-stereotypical behaviors, three experiments were conducted to analyze different categories of demands and tangible stimuli as well as different types of attention. These analyses were conducted to determine their respective functions as reinforcements for motor, vocal, and motor and vocal stereotypies. The data from this study demonstrate that it is possible to identify specific social variables that reinforce motor and/or vocal stereotypy when initial FA results indicate the behaviors were automatically reinforced. Differentiation in levels of stereotypy was demonstrated for all seven participants for each of the three experiments. The exception was Participant 7b, whose tangible analysis for vocal stereotypy did not show a differentiation in responding, which suggests the behavior is not influenced by access to tangible stimuli. However, his behavior for the demand and attention analyses shows that different types of demands and attention effected vocal stereotypy. Generally, it is recommended that extended alone conditions should be conducted when levels of behavior are high for all conditions to determine if the behavior is automatically reinforced. However, these data suggest that subsequent analyses to clearly determine the response-reinforcer relationship may be more appropriate to isolate the function of behavior. By conducting a systematic analysis of presumed automatically

51 36 reinforced behaviors, it may be possible to ascertain the particular reinforcing or punishing variables. This could allow for the development of more refined and effective treatments for stereotypical behavior as previously suggested. The FA data for P1, for instance, indicated that motor and vocal stereotypy were maintained by automatic reinforcement. With this initial information, a treatment involving blocking and redirecting or extinction may have been utilized. However, the supplemental demand analysis revealed that the behavior was sensitive to various types of demands: motor and vocal stereotypy increased with difficult demands compared to easy demands. When a treatment that involved demand fading was implemented the levels of stereotypy decreased to zero. A post-treatment demand analysis also indicated that stereotypy was at or near zero levels. It is evident that the behavior decreased to levels that are more acceptable with the demand fading procedure. When making a general conclusion that motor and vocal stereotypies are automatically reinforced, misidentifying the function may occur. Take for instance the data sets for P6a (motor)/p6b (vocal) and P7a (motor)/p7b (vocal) that were from the same children (e.g., P6a/P6b were one child and P7a/P7b were another child). Both of the children did engage in motor and vocal stereotypy; however, the behaviors did not occur in conjunction. In evaluating the data for P6a/P6b, the FAs indicated that motor and vocal stereotypy were automatically reinforced. The trends for the demand analyses and attention analyses are similar for both behaviors. These analyses reveal difficulty levels of demands and types of attention influence both motor and vocal stereotypy in the same manner. Motor and vocal stereotypies did not show similar patterns during the tangible analyses. Presented with these results, different, effective treatments can be employed to

52 37 reduce each behavior. These treatments may have been overlooked if the FA results were considered without the supplemental analyses. To illustrate, for P6b s vocal stereotypy, the treatment involved differential reinforcement of the absence of the target behavior and/or engaging in appropriate speaking. This treatment was effective in decreasing behavior. The post-treatment AA data indicated that the proportion of vocal stereotypy decreased during each of the conditions. For motor stereotypy (P6a), the treatment also involved a differential reinforcement procedure, except a preferred item was delivered for a fixed time when the target behavior did not occur for a set period. This period was gradually increased until motor stereotypy did not occur for the entire 10 min (600s) session. The post-treatment TA denoted that the proportion of motor stereotypy decreased. It is evident that both motor and vocal stereotypies decreased to acceptable levels with the differential reinforcement procedures. Data sets from P7a (motor) and P7b (vocal) were also from the same child. Again, the FAs for both motor and vocal stereotypy indicated that the behaviors were automatically reinforced. However, even though the behaviors were both stereotypical, the subsequent analyses did not produce similar results. The DA for this child revealed that vocal stereotypy (P7b) was highest during the moderately difficult condition, lowest for difficult condition and demonstrated a downward trend for the easy condition. This is unlike the DA data for motor stereotypy (P7a) where the behavior was highest for the difficult condition and behaviors where on a downward trend for both the easy and moderately difficult conditions. The movement towards dissimilar levels of motor and vocal stereotypy continued with the tangible and attention analyses. For this child, the

53 38 same treatment for motor and vocal stereotypy may not be effective in reducing the behavior since the function of stereotypical behaviors can be different for the same child. The data from these experiments expand on the current methodology to assess function of behavior to create treatments and reduce the detrimental effects of motor and/or vocal stereotypy. Decreasing stereotypical behaviors can help individuals spend quality time with family members and friends, improve their academic and vocational skills, and they can learn how to engage in appropriate social and play interactions with peers. By utilizing analyses such as those presented in this study, it is possible to implement treatments that can target the improvement of the above-mentioned social skills. These data also illustrate that one should not assume that stereotypical behaviors are not influenced by social contingencies and may be influenced by multiple variables. This may be especially beneficial since the goal of a functional analysis is the control and prediction of events related to behavior (Skinner, 1938). When behaviors are thought to be sensory based, it may be assumed that it is difficult to change the behavior and this may prevent an analysis of the function of stereotypy and, in turn, the reinforcer is not clearly identified. Even though behaviors may be unaffected by social variables, in that they can occur at high rates for all functional analytic conditions and in extended alone/ignore conditions or the data may be undifferentiated, it does not necessarily mean that they are maintained by automatic reinforcement. By having an assessment tool that assists in separating specific effects, it may be possible to decrease the number of false positive assessments that can lead to ineffective treatments.

54 39 These data support and expand the suggestions provided by Rapp & Vollmer (2005), Kennedy (2000), Miltenberger (2000), and Carr (2000) in that, when assessing function, one should 1) begin to create a systematic method for ruling-out social functions for self-stimulatory or automatically reinforced behaviors, 2) assess behaviors based on contingencies that influence the behavior in the natural environment, 3) evaluate the contexts in which behavior occur (how behavior occurs), and 4) assess within session patterns of responding. For some individuals, motor and/or vocal stereotypy may be a result of intermittent reinforcement in the form or either subtle or indirect contingencies. For instance, Spradlin and Girardeau (1966) noted that the body rocking of adults with developmental disabilities living in an assisted facility increased prior to meal times and when staff changes occurred. The authors then assessed situations and determined that these were the times when the residents received the least amount of attention from staff. By assessing other possible variables, it was discovered that adults were sensitive to the gradual changes in staff presence throughout their day. It was this sensitivity to environmental changes that increased the occurrence of body rocking. In a second article, Lerman, Iwata, Zarcone, & Ringdahl (1994) found that indirect, intermittent reinforcement (adjunctive behavior) maintained the stereotypical behaviors for a participant. Specifically, adjunctive behavior is a non-contingent behavior maintained by a reinforcing event that is the result of another reinforcing contingency. For this participant, rates of vocal stereotypy increased during conditions when edibles were available intermittently relative to other schedules of reinforcement. This article also points to the fact that other schedules of reinforcement, such as a conjugate schedule,

55 40 should be further evaluated when behavior is thought to be maintained by automatic reinforcement. Even though the data in this study provide information as to how systematic and subsequent analyses can provide relevant information pertaining to the function of motor and vocal stereotypies, there were some limitations. We did not assess other possible variables that could influence stereotypy. The variables that were assessed were derived from pre-assessments to determine level of difficulty with demands and preferences of tangible stimuli. For the attention analysis, the different types of attention utilized during the functional analyses were assessed. While there is a multitude of stimuli that could be assessed with these analyses, we picked those that may influence stereotypy significantly. Conducting these analyses with stimuli that are most relevant for individual participants may be beneficial to others. We also did not create a hierarchy for types of attention. It is possible to develop an attention categorization assessment to determine which types of attention are most, moderately, and least preferred by presenting various forms of attention and collecting data on behaviors like smiling, pushing away, crying, and laughing. Future studies may benefit in conducting assessments for attention analyses. The objective of the treatments were to demonstrate a treatment could be derived from each of the three experiments for each behavior, therefore; a treatment was not implemented for each participant. Treatments were implemented, for motor stereotypy with data from the tangible analysis, for vocal stereotypy with information from the attention analysis, and with motor and vocal stereotypy for the demand analysis.

56 41 It may be possible to create more systematic assessments and effective treatments by utilizing more direct analyses to determine the specific variables that influence motor and vocal stereotypy. These analyses allow the behaviors to be evaluated with respect to social variables that are accessible to the researcher rather than assuming the variables are covert or are difficult to analyze. It is then feasible to explain the function of behavior and develop treatments that change behavior beyond using reinforcer replacement, punishment, and noncontingent reinforcement.

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64 49 Table 1. Demographic characteristics for all participants and definitions of stereotypical behaviors. Participant Age Sex Diagnosis Behavior Definition of Behavior P1 9 years Male Autism Motor & Vocal Stereotypy Making high pitched/random vocalizations; rocking; waving fingers in face in an up/down motion P2 14 years Male Autism Motor & Vocal Stereotypy P3 10 years Male Autism Motor & Vocal Stereotypy P4 13 years Male Autism Vocal Stereotypy P5 13 years Male Autism Motor Stereotypy P6a* 11 years Male Autism Motor Stereotypy P6b* 11 years Male Autism Vocal Stereotypy P7a** 6 years Male Autism Motor Stereotypy Repeating sounds and phrases; body pressing Repeating sounds and phrases; body pressing Repeating sounds and phrases Body pressing Body pressing Repeating sounds and phrases Waving fingers and hands; rocking P7b** 6 years Male Autism Vocal Stereotypy Repeating sounds *same child who engages in motor and vocal stereotypy separately **same child who engages in motor and vocal stereotypy separately

65 50 Table 2. Functional behavior assessment results for all participants. Participant P1 P2 P3 P4 P5 P6a P6b P7a P7b Functional Behavior Assessment Conducted Functional Analysis Screening Tool Revised Functional Analysis Screening Tool Revised Functional Analysis Screening Tool Revised Functional Analysis Screening Tool Revised Functional Analysis Screening Tool Revised Functional Analysis Screening Tool Revised Functional Analysis Screening Tool Revised Functional Analysis Screening Tool Revised Functional Analysis Screening Tool Revised Result Automatic Automatic Automatic Automatic Automatic Automatic Automatic Automatic Automatic

66 51 Table 3. Summary of items utilized in functional analytic conditions for all participants. Participant Ignore Attention Tangible Play Demand P1 None Puzzle, ball popper, honey pot toy Doll Spin toy, pillow, drum Follow directions, identify pictures, matching P2 None Magna doodle, robin, chicken, butterfly, dinosaur P3 None Fire truck, ball, ABC apple P4 None Fire truck, floam, light wand P5 None Flower book, rain stick, 20 questions, view master P6a None Firetruck, light ball, hammer, dragon book P6b None Tank, toy story book, 20 questions, view master Bee IPad IPhone IPad Little green and red cars IPad Chicken, duck, toucan, frog, butterfly Ball popper, flower book, hammer Ball, bubbles, tank, playdoh Hammer, light wand, dragon book, green car Green squishy, Thomas train, flower book Light wand, coloring book/crayons, mouse book Math, comprehension questions, identify emotions Follow directions, identify pictures, body parts Follow directions, identify pictures, categories, features Identify pictures, locations, functions, people Identify pictures, categories, shapes, yes/no Identify pictures, categories, features

67 52 Table 3 (continued). Summary of items utilized in functional analytic conditions for all participants. Participant Ignore Attention Tangible Play Demand P7a None Light wand, blue ball, tank, book IPad P7b None Pom-pom, book, floam, green squishy IPad 20 questions, kaleidoscope, ball, shark toy, paddle ball View master, light wand, spin toy, squishy Follow directions, identify body parts, 2-step directions Follow directions, identify category, pictures, color, features

68 53 Table 4. Demands utilized during Demand Analysis conditions for Participant 1. Easy Demand Moderately Difficult Difficult Demands Demands A firetruck is red, what Do this pincher grip What animal says woof color is a firetruck What does a duck say Touch index fingers What animal says moo Say I love you Point to sad What animal says quack Do this stomp feet Point to surprised What animal says meow Do this blow Point to dump truck What does a cow say Say no Do this pointer to palm What does a dog say Say hi Do this clasp hands What comes after spring Say I like Show me thumbs up What comes before summer Say I hop Do this wiggle fingers What comes after a What does a cat say Touch pencil What comes after b Touch highlighter Point to truck What comes before 4 Give me five Point to angry What comes before 2 Touch clicker Point to motorcycle What comes after 1 Do this lips together Point to helicopter What color is a firetruck Touch head Point to tractor What color is the wall Do this jump Point to doing homework What color is grass Do this open mouth Point to happy What color is the sky Do this peace sign Point to cutting What color is dirt Do this clap Do this walk forward Grass is green, what is green Do this thumbs up Touch timer Sky is blue, what is blue

69 54 Table 5. Demands utilized during Demand Analysis conditions for Participant 2. Easy Demand What could you do with a muffin? What could you do with a bee? What happens before you each cookies? What happens before you cook? What happens before you eat veggies? What happens before you play with blocks? What happened before they were unhappy? What happen before she was happy? What happened before they visited grandma? Why did they argue? Why are they arguing over the animal? Why are they taking a test? Why is she disgusted? Why is he disgusted? Why is he angry? What could you do with a pie? What could you do with blueberries? What could you do with a piano? Why is she surprised? Why are they doing homework? Moderately Difficult Demands Why is she angry? Why is she sad? Why is he sad? What is he sad? Why is he happy? Why is she happy? What happened before the puzzle? What could do with a cable car? What happened before sleeping? What happened before dancing? What happened before he fell? What happened before laughing? What happened before planting a tree? Why are they selfish? Why are they sharing? Why is the car in trouble? Why are they building? Why are they looking at pictures? Why are they reading? Why is she surprised? Difficult Demands 5/7 6/7 4/4 3/4 4/8 2/8 5/10 8/10 3/8 3/8 4/7 7/7 2/8 7/8 Simplify 10/45 Simplify 12/68 Simplify 15/85 Simplify 6/14 Simplify 4/18 Simplify 4/32 Simplify 10/36 Make into fraction 8 6/13 Make into fraction 6 2/17 Make into fraction 5 9/11 Make into fraction 2 6/17 Make into fraction 8 6/13 Make into fraction 3 2/9

70 55 Table 6. Demands utilized during Demand Analysis conditions for Participant 3. Easy Demand Moderately Difficult Difficult Demands Demands Say yo Identify clothing Identify desk Say pay Identify food Identify crib Say bi Identify toys Identify van Say pow Identify apple Identify bed Say ve Identify fruit Identify boat Say boo Identify banana Identify dirt Say bou Close eyes Identify comb Touch shoulders Touch leg Identify stairs Say bay Stick out tongue Identify candy Identify cookies Touch toes Identify dress Identify food Identify peanut butter Say dog Identify transportation Identify watermelon What s wrong? Different color Identify clothing Identify corn dog What s wrong? Third eye Identify food Identify airplane What s wrong? Broken Identify broccoli Identify bed What s wrong? Eating CD Identify cheese Identify hot dog What s wrong? Hat on Sit down Identify jello What s wrong? In road Stand up Identify cereal What s wrong? Flower Touch head Identify butter What s wrong? Hat Identify corn Identify teddy bear Say 5

71 56 Table 7. Demands utilized during Demand Analysis conditions for Participant 4. Easy Demand Identify category Identify clarinet Identify flamingo Identify mouth Identify trumpet Identify disgusted Identify transportation Identify food Identify food Identify transportation Why is she in bed? Why is she sad? Identify angry Identify disgusted Identify angry Identify instrument Identify transportation Identify crab Identify arm Identify ladybug Moderately Difficult Demands Identify sad Identify nuts Why is he concentrating? Identify cymbals Identify pen Where can you buy blueberries? Where can you buy nails? Identify balloon Identify harvester Identify mail man Identify lawyer Where can you find cars? Where can you find a barn? Which one is over? Identify librarian Which one is beside? Where can you find them arguing? What is wrong? eating a shoe What is wrong? double headed toothbrush Identify surprised Difficult Demands What happened after the girls visited grandma? Identify rolling pin Identify measuring cup Why is she scared? Why is she happy? Why is he excited? Why is she happy? What is wrong? stuffed animal to clean What is wrong? paint on her face What is wrong? fly is in the juice What is wrong? swing is broken What is wrong? trash is not in the can Where can you buy pajamas? What happened after they played with block? What happened after the mom played with the baby? What happened after they cooked together? What happened when the boy feel off the bike?

72 57 Table 8. Demands utilized during Demand Analysis conditions for Participant 5. Easy Demand Moderately Difficult Difficult Demands Demands Identify category Identify space shuttle What happened after they read a book Identify nose Where can you buy it? What is she happy? Identify blender Where can you buy it? What is she upset? Identify quail Identify grasshopper Identify earwig Identify food Identify category Identify deer Why is she practicing Identify forklift Identify centipede Identify puffin Identify back Identify roach Identify ray Why is she happy What happened after she cleaned her room? Identify praying mantis Where can you find them sharing? What is wrong? Banana as phone Identify saw Where can you find a nurse? What is wrong? Different boots Identify happy Which one is between? What is wrong? Eyes different Identify category Which one is below? What is wrong? Doll to erase Identify category Identify lifeguard What happened after they hugged? Identify everyday objects Where can you find a roller coaster? What happened after they played? Identify food Where can you find a harp? What happened after they planted a tree? Why is he happy Where can you find a bee? Where can you buy pie? Why is she angry Identify screw What happened after the fight? Why is he excited What is wrong? Cow with boots What happened after eating vegetables? Why is he happy What is wrong? Warm clothes at beach Why is he happy? What is wrong? Golf ball Why is he sad Identify unicycle What body part

73 58 Table 9. Demands utilized during Demand Analysis conditions for Participant 6a. Easy Demand Moderately Difficult Difficult Demands Demands Do this wave Identify category Which one is around? Identify toothpaste Identify male What does a say? Identify balloon Identify vase Which one is toward? Identify fingers Identify female Identify golf cart Identify clownfish Identify sea turtle Say orange Identify category Show me hugging Which one is opposite Identify food Identify female Identify lawyer Which one is in? Identify rat Identify manatee Identify kiwi Identify shoulder Identify farm item Identify male Identify female Identify wheelchair Identify paper towels Identify male Identify mechanic Identify category Identify animal Identify steak Identify logger How is she feeling? Which one is up Identify category Identify janitor Which one is before Identify 17 Identify envelope Identify instrument Identify animal Which one is behind Identify hamster Which one is outside? Identify taxi cab Identify category Identify female What is she doing? Identify newscaster Show me clapping Identify barn Identify artichoke Identify camel Identify lifeguard Identify motor home

74 59 Table 10. Demands utilized during Demand Analysis conditions for Participant 6b. Easy Demand Moderately Difficult Difficult Demands Demands Identify female Identify male Which one is beneath? Identify starfish Rub your hands and tap Which one is through? teeth Identify 10 Identify category Identify category Which one is inside? Identify female Which one is against? Identify female Identify nurse Which one is down? Identify scooter Identify globe Identify category Identify category Identify pelican Identify station wagon Identify eagle Which one is on? Which one is near? Which one is under? Identify swan Identify musician Identify category Identify killer whale Identify male Identify transportation Identify transportation Identify tool Show me scratching Identify light bulb Identify fly Touch nose Pointer finger to palm and rub hands Identify ferret How is she feeling? Identify pear Identify female Identify scorpion Which one is off? Identify male Identify category Identify category What is she doing? Identify jockey Identify ear How is she feeling? Identify trombone Identify 14 Make a peace sign and tap teeth Identify bacon Identify fork lift Identify hay Identify toilet paper Identify category Identify everyday object

75 60 Table 11. Demands utilized during Demand Analysis conditions for Participant 7a. Easy Demand Moderately Difficult Difficult Demands Demands Identify red Identify ship Say c Identify j Identify chair What says tweet? Identify m Identify bulldozer Say bye Identify apple Identify hexagon A, B Clap hands Identify arrow Say boo Identify brown Clap hands and tap legs Say key Identify t Open and close hands Nod head Identify black Say b W, X, Y, Identify flower Identify shoes Identify mouth Identify rectangle Identify spoon The cat says Stand up Identify u Look left Identify goat Identify z Hickory, dickory, Identify gummy bears Identify corn What says baa Identify o Tap legs Say bo Touch mouth Identify jacket Row, row, row, your Identify blue Identify tiger Touch ear Identify moon Close mouth The cow says Identify bed Touch fingers together Say bay Touch head Chomp teeth Identify head Touch nose Identify fire truck Touch pointer finger to thumb

76 61 Table 12. Demands utilized during Demand Analysis conditions for Participant 7b. Easy Demand Moderately Difficult Difficult Demands Demands Identify lion Clap and clasp hands Say bee Identify soap Open mouth Wave Identify gray Identify mouth Ready, set, Clap Identify flower Say bo Identify star Identify car What says neigh? Identify I Open hands Say b Identify tomatoes Identify ice cream Wiggle fingers Put lips together Identify cookies The pig says Identify w Identify motorcycle London bridge is falling Identify ball Identify s Say ca Identify white Identify circle Touch shoulders Identify leg Touch fingers Identify eye Identify elephant Clasp hands Twinkle, twinkle, little Identify green Identify bird Say ki Identify n Identify k What says hoot? Identify orange Identify cupcake Smile Identify oval Identify ear The dog says Identify p Identify rhino Identify chin Rub chest Identify alligator 1, 2, Sit down Identify duck Say bi

77 62 Table 13. Leisure items utilized in the Tangible Analyses for all participants. Highly Preferred Moderately Least Preferred Preferred P1 Bunny Blue spike ball Elmo phone P2 Magna doodle Robin Duck P3 Pin toy Kaleidoscope Guitar P4 IPad Yellow squishy toy Connecting shark toy P5 Play doh IPod Magic 8 ball P6a IPad Bean box White board/crayons P6b Edward train Story cubes Wand P7a ABC text & go IPad Book P7b Squishy Blue car Spirograph

78 Proportion of Intervals for Motor & Vocal Stereotypy 63 Figure 1. Results of the Functional Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions ignore attention tangible play demand Session

79 Proportion of Intervals for Motor & Vocal Stereotypy 64 Figure 2. Results of the Functional Analysis for Participant 2. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions ignore attention tangible play demand Session

80 Proportion of Intervals for Motor & Vocal Stereotypy 65 Figure 3. Results of the Functional Analysis for Participant 3. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Ignore Attention Tangible Play Demand Session

81 Proportion of Intervals for Motor & Vocal Stereotypy 66 Figure 4. Results of the Functional Analysis for Participant 4. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Ignore Attention Tangible Play Demand Session

82 Proportion of Intervals for Motor & Vocal Stereotypy 67 Figure 5. Results of the Functional Analysis for Participant 5. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Ignore Attention Tangible Play Demand Session

83 Proportion of Intervals for Motor & Vocal Stereotypy 68 Figure 6. Results of the Functional Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Ignore Attention Tangible Play Demand Session

84 Proportion of Intervals for Motor & Vocal Stereotypy 69 Figure 7. Results of the Functional Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Ignore Attention Tangible Play Demand Session

85 Proportion of Intervals for Motor & Vocal Stereotypy 70 Figure 8. Results of the Functional Analysis for Participant 7a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Ignore Attention Tangible Play Demand Session

86 Proportion of Intervals for Motor & Vocal Stereotypy 71 Figure 9. Results of the Functional Analysis for Participant 7b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Ignore Attention Tangible Play Demand Session

87 Proportion of Intervals for Motor & Vocal Stereotypy 72 Figure 10. Results of the Demand Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

88 Proportion of Intervals for Motor & Vocal Stereotypy 73 Figure 11. Results of the Demand Analysis for Participant 2. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

89 Proportion of Intervals for Motor & Vocal Stereotypy 74 Figure 12. Results of the Demand Analysis for Participant 3. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

90 Proportion of Intervals for Motor & Vocal Stereotypy 75 Figure 13. Results of the Demand Analysis for Participant 4. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

91 Proportion of Intervals for Motor & Vocal Stereotypy 76 Figure 14. Results of the Demand Analysis for Participant 5. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

92 Proportion of Intervals for Motor & Vocal Stereotypy 77 Figure 15. Results of the Demand Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

93 Proportion of Intervals for Motor & Vocal Stereotypy 78 Figure 16. Results of the Demand Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

94 Proportion of Intervals for Motor & Vocal Stereotypy 79 Figure 17. Results of the Demand Analysis for Participant 7a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

95 Proportion of Intervals for Motor & Vocal Stereotypy 80 Figure 18. Results of the Demand Analysis for Participant 7b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

96 Proportion of Intervals for Motor & Vocal Stereotypy 81 Figure 19. Results of the Demand Analysis treatment for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred throughout demand fading E= 20 E= 15; M= 5 E= 10; M =10 E= 5; M= 15 M=20 M=15; D=5 M= 10; D=1 M = 5; D =15 D= Participant Sick Session

97 Proportion of Intervals for Motor & Vocal Stereotypy 82 Figure 20. Results of the mid-treatment Demand Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

98 Proportion of Intervals for Motor & Vocal Stereotypy 83 Figure 21. Results of the post-treatment Demand Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Easy Moderately Difficult Difficult Session

99 Percentage Selected 84 Figure 22. Results of the preference assessment for Participant 1. Data reflect the percentage of times each item was selected. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Bunny Blocks Blue Spikey Ball Pin Toy Tangrams Bubble Gum Machine Stimuli Elmo Phone

100 Percentage Selected 85 Figure 23. Results of the preference assessment for Participant 2. Data reflect the percentage of times each item was selected. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Stimuli

101 Percentage Selected 86 Figure 24. Results of the preference assessment for Participant 3. Data reflect the percentage of times each item was selected. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Stimuli

102 Percentage Selected 87 Figure 25. Results of the preference assessment for Participant 4. Data reflect the percentage of times each item was selected. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Stimuli

103 Percentage Selected 88 Figure 26. Results of the preference assessment for Participant 5. Data reflect the percentage of times each item was selected. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Play Doh IPOD Paddle Ball Ball Book Magic 8 Ball Stimuli Spirograph

104 Percentage Selected 89 Figure 27. Results of the preference assessment for Participant 6a. Data reflect the percentage of times each item was selected. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% IPAD Bean Box Puzzle Sandbox Green Squishy Toy Stimuli Train White Board & Crayons

105 Percentage Selected 90 Figure 28. Results of the preference assessment for Participant 6b. Data reflect the percentage of times each item was selected. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Edward Train Furby Story Cubes Play Doh Ball Rain Stick Wand Stimuli

106 Percentage Selected 91 Figure 29. Results of the preference assessment for Participant 7a. Data reflect the percentage of times each item was selected. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% ABC - Text & Go IPAD V-Reader Hammer Ball Firetruck Book Stimuli

107 Percentage Selected 92 Figure 30. Results of the preference assessment for Participant 7b. Data reflect the percentage of times each item was selected. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Squishy Blue Car Hammer Book Ball A Hero's Quest Stimuli Spirograph

108 Proportion of Intervals for Motor & Vocal Stereotypy 93 Figure 31. Results of the Tangible Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Highly preferred Moderately preferred Least preferred Session

109 Proportion of Intervals for Motor & Vocal Stereotypy 94 Figure 32. Results of the Tangible Analysis for Participant 2. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Highly Preferred Moderately Preferred Least Preferred Session

110 Proportion of Intervals for Motor & Vocal Stereotypy 95 Figure 33. Results of the Tangible Analysis for Participant 3. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Highly Preferred Moderately Preferred Least Preferred Session

111 Proportion of Intervals for Motor & Vocal Stereotypy 96 Figure 34. Results of the Tangible Analysis for Participant 4. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Highly Preferred Moderately Preferred Least Preferred Session

112 Proportion of Intervals for Motor & Vocal Stereotypy 97 Figure 35. Results of the Tangible Analysis for Participant 5. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Highly Preferred Moderately Preferred Least Preferred Session

113 Proportion of Intervals for Motor & Vocal Stereotypy 98 Figure 36. Results of the Tangible Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Highly Preferred Moderately Preferred Least Preferred Session

114 Proportion of Intervals for Motor & Vocal Stereotypy 99 Figure 37. Results of the Tangible Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Highly Preferred Moderately Preferred Least Preferred Session

115 Proportion of Intervals for Motor & Vocal Stereotypy 100 Figure 38. Results of the Tangible Analysis for Participant 7a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Highly Preferred Moderately Preferred Least Preferred Session

116 Proportion of Intervals for Motor & Vocal Stereotypy 101 Figure 39. Results of the Tangible Analysis for Participant 7b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Highly Preferred Moderately Preferred Least Preferred Session

117 Proportion of Intervals for Motor & Vocal Stereotypy 102 Figure 40. Results of the Tangible Analysis treatment for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred throughout phases Base -line 5s 10s 20s 40s 80s 160s 320s 600s Session

118 Proportion of Intervals for Motor & Vocal Stereotypy 103 Figure 41. Results of the post-treatment Tangible Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Highly Preferred Moderately Preferred Least Preferred Session

119 Proportion of Intervals for Motor & Vocal Stereotypy 104 Figure 42. Results of the Attention Analysis for Participant 1. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Physical Touch Statement of Concern Reprimand Session

120 Proportion of Intervals for Motor & Vocal Stereotypy 105 Figure 43. Results of the Attention Analysis for Participant 2. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Physical Touch Statement of Concern Reprimand Session

121 Proportion of Intervals for Motor & Vocal Stereotypy 106 Figure 44. Results of the Attention Analysis for Participant 3. Data reflect the proportion of intervals containing motor and vocal stereotypy that occurred in the experimental conditions Physical Touch Statement of Concern Reprimand Session

122 Proportion of Intervals for Motor & Vocal Stereotypy 107 Figure 45. Results of the Attention Analysis for Participant 4. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Physical Touch Statement of Concern Reprimand Session

123 Proportion of Intervals for Motor & Vocal Stereotypy 108 Figure 46. Results of the Attention Analysis for Participant 5. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Physical Touch Statement of Concern Reprimand Session

124 Proportion of Intervals for Motor & Vocal Stereotypy 109 Figure 47.Results of the Attention Analysis for Participant 6a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Physical Touch Statement of Concern Reprimand Session

125 Proportion of Intervals for Motor & Vocal Stereotypy 110 Figure 48. Results of the Attention Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Physical Touch Satement of Concern Reprimand Session

126 Proportion of Intervals for Motor & Vocal Stereotypy 111 Figure 49. Results of the Attention Analysis for Participant 7a. Data reflect the proportion of intervals containing motor stereotypy that occurred in the experimental conditions Physical Touch Statement of Concern Reprimand Session

127 Proportion of Intervals for Motor & Vocal Stereotypy 112 Figure 50. Results of the Attention Analysis for Participant 7b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Physical Touch Statement of Concern Reprimand Session

128 Proportion of Intervals for Motor & Vocal Stereotypy 113 Figure 51. Results of the Attention Analysis treatment for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred during phases Statement of Concern DRO - Statements Contingent on No Vocal Stereotypy Physical Touch DRO - Physical Touch Contingent on No Vocal Stereotypy Session

129 Proportion of Intervals for Motor & Vocal Stereotypy 114 Figure 52. Results of the post-treatment Attention Analysis for Participant 6b. Data reflect the proportion of intervals containing vocal stereotypy that occurred in the experimental conditions Physical Touch Satement of Concern Reprimand Session

130 115 Appendix A. Example of Functional Analysis Screening Tool - Revised. Appendix 2